Large Amount Questionnaire - AIA Singapore

AIA SINGAPORE

LARGE AMOUNT QUESTIONNAIRE

Particulars of Insured and Policy Owner Name of Insured

NRIC/Passport/FIN No.

Name of Policy Owner

NRIC/Passport/FIN No.

Policy Numbers

For Applicant/Owner application, please complete this questionnaire based on Insured's profile. Where the insured is a juvenile, please complete this questionnaire based on Applicant /Owner's profile.

All figures in this questionnaire are in Singapore Currency. Please specify if you wish to use other currency.

Part 1

Type of Assets Personal Use Assets

Net Worth Value/ Amount

% of ownership

Income

Type of Income

Annual Income

Employment

Residential property Others, please specify:

% Commissions % Business

Total Personal Use Assets

% Investment Income

Invested Assets Investment (eg shares, unit trusts) Others, please specify:

Total Invested Assets

Rental Income

%

Others, please specify: ____________________

% Total Annual Income

Remarks- Please provide any additional

%

information that you feel will be helpful in processing your application.

Cash/ Cash Equivalent

Bank Deposits Others, please specify:

Total cash/ Cash Equivalent

Total Assets (A)

*G190921*

*G190921*

AIA Singapore Private Limited (Reg No. 201106386R) New BusinePsasgDe e1poafrt3ment, 3 Tampines Grande, #09-01, AIA Tampines, Singapore 528799

AIA Customer Care Hotline: 1800 248 8000 .SG

Liabilities

Mortgage Loan

%

Others, please specify:

%

Total Liabilities (B)

%

Net Worth (A) ? (B)

Part 2: For Self-employed, Non-Income Earners, Employees where commissions contribute > 30% of income and Non-

Residents of Singapore ( In addition to Part 1)

1. Income details

Last Year

2 years ago

3 years ago

Earned Income (salary/ director fees)

Other Earned Income (bonuses/ commissions)

Annual Perks and Allowances

Unearned Income

Dividends from shares/investment income/ Interests from fixed bank deposits

Income from rental of properties

Other Income, please specify:

2. Please list the full address of the properties you own.

Property 1 Property 2 Property 3

Property Address

% of ownership

3. Details of Main Business Interest

Name of Company Nature of Business Responsibility and Duties: Paid Up Capital

% of ownership

% When start / brought into Business:

4. Details of Company Account

Last Year Revenue Gross Profit Profit before Tax Total Assets Total Liabilities

2 years ago Page 2 of 3

3 years ago

 5. Details of other business interest ( if any )

Company Name

Position

6. Non Income Earner - Please indicate the details of your spouse or parents

Name

Date of Birth

Occupation

Details of Insurance Cover

Insurance Company

Type of Cover

Date of Appointment

% of Ownership

%

%

Relationship to Insured Annual Income

Sum Assured

7. Remarks- Please provide any additional information that you feel will be helpful in processing your application.

Confidentiality and Confirmation

AIA Singapore Private Limited ("AIA Singapore") shall at all times maintain all information provided in this questionnaire in strict con f i de n c e a n d s h a l l n o t i n t he ordinary course of its business disclose this information or any part thereof without the express authority of the Applicant. I, the policyholder / Insured confirm that the information provided herein is full, complete and true, and I agree that the information provided forms a part of the p o l i c y issued, amended or reinstated where this information is relied upon by AIA Singapore. I will supply adequate proof of the statements made in this document a s a n d when requested by AIA Singapore.

Signature of Policyholder ( Applicant/ Owner) / Insured

Date: Insurance Adviser (IA)'s Name

IA's Code

IA's Unit Name

Mobile No.

Page 3 of 3

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